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Investigation and inquest
On 27 January 2014 I commenced an investigation into the death of Ralph Stephen Goslin, aged 40. The investigation concluded at the end of the inquest on 18 June 2014. The jury’s determination made at inquest was by way of a narrative, which I attach.
Circumstances of the death
Mr Goslin was an inpatient at St Pancras Hospital on Montagu Ward, detained under Section 3 of the Mental Health Act. He suffered with schizophrenia and also epilepsy.
He was found unresponsive in the bath on 21 June 2014, and died later that day in University College Hospital.
The jury recorded his medical cause of death as:
1a seizure related death (seizure alone or with drowning) in epilepsy
1b grade IV glioblastoma
Coroner’s concerns
1. The junior doctor at St Pancras Hospital who first reviewed the UCH blood test result giving Mr Goslin’s sodium valproate level as less than 3, did not realise that this was sub therapeutic, because the reference range was given as less than 100, rather than 50-100 as it is in some other hospitals. This meant that Mr Goslin’s failure to take his anti epilepsy medication was not recognised as quickly as it could have been.
Information checked against the published report and official responses